Hidden Costs of Hospitalization After Firearm Injury: National Analysis of Different Hospital Readmission

To compare the risk factors and costs associated with readmission after firearm injury nationally, including different hospitals. No national studies capture readmission to different hospitals after firearm injury. The 2013 to 2014 Nationwide Readmissions Database was queried for patients admitted after firearm injury. Logistic regression identified risk factors for 30-day same and different hospital readmission. Cost was calculated. Survey weights were used for national estimates. There were 45,462 patients admitted for firearm injury during the study period. The readmission rate was 7.6%, and among those, 16.8% were readmitted to a different hospital. Admission cost was $1.45 billion and 1-year readmission cost was$131 million. Sixty-four per cent of those injured by firearms were publicly insured or uninsured. Readmission predictors included: length of stay >7 days [odds ratio (OR) 1.43, P 15 (OR 1.41, P < 0.01), and requiring an operation (OR 1.40, P < 0.01). Private insurance was a predictor against readmission (OR 0.81, P < 0.01). Predictors of readmission to a different hospital were unique and included: initial admission to a for-profit hospital (OR 1.52, P < 0.01) and median household income ≥$64,000 (OR 1.48, P < 0.01). A significant proportion of the national burden of firearm readmissions is missed by not tracking different hospital readmission and its unique set of risk factors. Firearm injury-related hospitalization costs$791 million yearly, with the largest fraction paid by the public. This has implications for policy, benchmarking, quality, and resource allocation

Validating the ATLS Shock Classification for Predicting Death, Transfusion, or Urgent Intervention

The Advanced Trauma Life Support (ATLS) shock classification has been accepted as the conceptual framework for clinicians caring for trauma patients. We sought to validate its ability to predict mortality, blood transfusion, and urgent intervention. We performed a retrospective review of trauma patients using the 2014 National Trauma Data Bank. Using initial vital signs data, patients were categorized into shock class based on the ATLS program. Rates for urgent blood transfusion, urgent operative intervention, and mortality were compared between classes. 630,635 subjects were included for analysis. Classes 1, 2, 3, and 4 included 312,404, 17,133, 31, and 43 patients, respectively. 300,754 patients did not meet criteria for any ATLS shock class. Of the patients in class 1 shock, 2653 died (0.9%), 3123 (1.0%) were transfused blood products, and 7115 (2.3%) underwent an urgent procedure. In class 2, 219 (1.3%) died, 387 (2.3%) were transfused, and 1575 (9.2%) underwent intervention. In class 3, 7 (22.6%) died, 10 (32.3%) were transfused, and 13 (41.9%) underwent intervention. In class 4, 15 (34.9%) died, 19 (44.2%) were transfused, and 23 (53.5%) underwent intervention. For uncategorized patients, 21,356 (7.1%) died, 15,168 (5.0%) were transfused, and 23,844 (7.9%) underwent intervention. Almost half of trauma patients do not meet criteria for any ATLS shock class. Uncategorized patients had a higher mortality (7.1%) than patients in classes 1 and 2 (0.9% and 1.3%, respectively). Classes 3 and 4 only accounted for 0.005% and 0.007%, respectively, of patients. The ATLS classification system does not help identify many patients in severe shock

Alcohol/Illicit Substance Use in Fatal Motorcycle Crashes

The objective of the current study is to determine how alcohol and illicit substance use contributes to motorcycle crash fatalities by examining the relationship between toxicology levels found postmortem and the behavior of riders and passengers in fatal motorcycle crashes. All motorcycle fatalities in Miami-Dade County, FL, from 2009 to 2014 were reviewed using the Miami-Dade County Medical Examiner's toxicology reports and the corresponding crash reports. Positive alcohol/illicit substance detection was found in 44% of our population of 227 fatalities. When compared with those with a negative alcohol/illicit substance detection, those with a positive alcohol/illicit substance detection were more likely to be found at fault of the crash (77% versus 50%, P < 0.001), more likely to be in a single-vehicle crash (47% versus 21%, P < 0.001) and less likely to wear a helmet (44% versus 64%, P = 0.002). However, there was no significant relationship between speeding and alcohol/illicit substance detection (29% versus 33%, P = 0.748). In addition, a regression analysis demonstrated that there was less helmet use and more single-vehicle crashes with higher blood alcohol concentration. In fatal motorcycle crashes, alcohol and illicit substance use had a significantly negative impact on the risk aversion of motorcycle fatalities in regard to fault, helmet use, and single-vehicle crashes

Appendicitis in Pregnancy: A Post-Hoc Analysis of an EAST Multicenter Study

To compare the presentation, management, and outcomes of appendicitis in pregnant and non-pregnant females of childbearing age (18-45 years). This was a post-hoc analysis of a prospectively collected database (January 2017-June 2018) from 28 centers in America. We compared pregnant and non-pregnant females' demographics, clinical presentation, laboratory data, imaging findings, management, and clinical outcomes. Of the 3,597 subjects, 1,010 (28%) were of childbearing age, and 41 were pregnant: The mean age of the pregnant subjects was 30 ± 8 years at a median gestational age of 15 (range 10-23) weeks. The two groups had similar demographics and clinical presentation, but there were differences in management and outcomes. For example, in pregnant subjects, abdominal ultrasound scans (US) plus magnetic resonance imaging (MRI) was the most frequently used imaging method (41%) followed by MRI alone (29%), US alone (22%), computed tomography (CT) (5%), and no imaging (2%). Despite similar American Association for the Surgery of Trauma Emergency General Surgery Clinical and Imaging Grade at presentation, pregnant subjects were more likely to be treated with antibiotics alone (15% versus 4%; p = 0.008). Pregnant subjects were less likely to have simple appendicitis and were more likely to have complicated (perforated or gangrenous) appendicitis or a normal appendix. With the exception of index hospital length of stay, there were no significant differences between the groups in clinical outcomes at index hospitalization or at 30 days. Almost 1 in 20 women of childbearing age presenting with appendicitis is pregnant. Appendicitis most commonly affects women in early to mid-pregnancy. Compared with non-pregnant women of childbearing age, pregnant women presenting with appendicitis undergo non-operative management more often and are less likely to have simple appendicitis. Compared with non-pregnant patients, they have similar clinical outcomes at both index hospitalization and 30 days after discharge

A survey of the practice and attitudes of surgeons regarding the treatment of appendicitis

We surveyed surgeons to document their attitudes, practice, and risk tolerance regarding the treatment of appendicitis. A web-based survey was sent to the EAST membership. The primary composite endpoint was defined as 1-year incidence of perioperative complications, antibiotic failure, infections, ED visits, and readmissions. A total of 563 of 1645 surveys were completed (34% response). Mean age was 47 ± 10 years and 98% were from the United States. Most (72%) were employed at academic teaching hospitals and 66% practiced in an urban setting. There were significant differences in treatment recommendations for different presentations of appendicitis. Regarding the primary composite endpoint, surgeons would tolerate a median 17% [10%–25%] excess morbidity in order to avoid an operation (i.e. non-inferiority) and would require a median 24% [10%–50% lower morbidity for the surgical approach in order to declare it a superior treatment (i.e. superiority). To be considered non-inferior, antibiotic therapy of appendicitis cannot have >17% excess morbidity and appendectomy must have at least 24% lower morbidity to be considered superior. •Open appendectomy is no longer favored.•There is wide disparity in the current treatment of appendicitis in the United States.•Surgeons are willing to tolerate up to 17% excess morbidity in order to avoid an operation (non-inferiority of medical treatment).•Surgeons are willing to tolerate up to 17% excess morbidity in order to avoid an operation (medical non-inferiority)